My step-mother was denied 5 days before her surgery! She has Cigna. Evidently, Cigna instituted a new policy April 1, 2003, stating that a patient must be on a medically supervised weightloss program for 26 consecutive weeks or they will not be eligable for gastric bypass. My step-mother is devastated! There is only 1 doctor in the state of Vermont who does this surgery, and she started this whole process nearly 2 years ago. It took her 1 year to get an initial appointment, and 10 months to get a surgery date......only to get denied 5 days before her surgery!!! The salt on the wound is that my step-mother has been on a weight loss program for 3 years...but her PCP's secretary didn't state that it was for weight loss, but for diabetes(which that was not totally correct!!), and because she didn't state "weight loss" Cigna denied it!
In their own letter they stated "Though this surgery is medically necessary, we are denying you." How can they find a covered procedure medically necessary, yet still NOT cover it???
Of course she is appealing, but now she has lost her surgery date. The best she can hope for is possibly November or December if her appeal is heard within the next 30 days!
Something needs to be done about these insurance companies! It's ridiculous!
I told my step-mother, and I will tell you...squeeky wheel gets the grease!! Do you know how many people probably get denied and give up??? That is what the insurance companies are hoping for. When you write your appeal letter copy everyone from the Governor to your Senator and congressman, to the head of the New Jersey Banking and Insurance commission. Complain to whomever will hear you. Your insurance carrier will get the point.